Forequarter Amputation for Malignant Tumours: Tale of Sustained Relevance or Telltale Sign of Doom?

Forequarter amputation (interscapulothoracic amputation) includes surgical removal of an upper limb and the shoulder girdle, including the scapula and a portion of the clavicle. We aim to report about our recent experience of having to resort to this mutilating surgery and the clinicopathological variables in that context. The study was done at a cancer centre in Northeast India. It was an ambispective study design, where the patient cohort who underwent FQA was identified retrospectively from the operative register of major surgeries for the time period 1st June 2020 to 31st May 2022 (24 months), and these patients were followed up prospectively from 1st June 2022 to 31st May 2023 (1 year). The study variables were obtained from the electronic medical records (EMR), the physical case files and the hospital-based cancer registry (HBCR). There were 7 patients who underwent forequarter amputation (FQA) during the two years, and in the same period, 15 patients underwent limb salvage surgery for tumours around the shoulder girdle. This translates to a FQA rate of 31.8%. The male:female ratio of the patients was 3:4. The median age of the patients was 32 years (range 19 to 59 years). The histologies included osteosarcoma (2), chondrosarcoma (2), Ewing's sarcoma (2) and hidradenocarcinoma (1). None of these patients had any distant metastatic disease. Four patients had local disease progression on neoadjuvant chemotherapy. Three of the patients had emergency surgery as a life-saving procedure on account of bleeding from their ulcerated tumours. Two patients had disease which was recurrent and unsalvageable due to the encasement of the neurovascular bundle. The median follow-up was 8 months (range 4 to 18 months). Five patients had distant recurrence with pulmonary metastases (100%) and bone secondaries (14.3%) within a range of 3 to 8 months. None of the patients had any local recurrence. Two patients are on follow-up without any evidence of disease (17 and 18 months respectively). Forequarter amputation is the surgical option when tumours around the shoulder girdle are not amenable to limb-sparing procedures by virtue of their disease extent. These cancers are usually aggressive leading to early distant metastasis.

Outcomes Of The Combined Anteroposterior Approach For Forequarter Amputation In Shoulder Girdle Tumours.

BACKGROUND: Forequarter amputation (FQA) is the surgical treatment of choice for tumours in the upper extremity and shoulder girdle that infiltrate the neurovascular bundle, shoulder joint and muscles of the shoulder girdle in non-salvageable cases. In both curative and palliative settings, FQA can serve as an effective oncological treatment for local control of tumour. METHODS: All patients who underwent FQA in our unit from January 2016 till August 2019 for oncological indications were included in our study and their clinical outcomes were calculated. RESULTS: Thirteen patients were included in the study including 8 male patients. Mean age of patients at surgery was 20 years (Range 10-53 years) with a minimum follow up of 6 months or till patient was deceased earlier. Six patients had primary osteosarcoma, 4 had Ewing's sarcoma, 2 had Spindle cell sarcoma while 1 had Giant cell tumour. Six patients underwent surgery with curative intent. No major per operative complication was encountered in any of the cases with a mean blood loss of 350 ml and mean duration of surgery being 75 minutes. At last, follow up only 6 patients were alive, with 2 patients alive with disease (Metastasis) and undergoing palliative treatment. None of our patients had local recurrence. Mean survivorship for the whole cohort was 9.2 months (Range 3-18 months) with a mean survivorship for the deceased group was 7.1 months (Range 3-16 months) and mean survivorship for alive patients was 11.6 months (range 9-18 months). All the alive patients had phantom limb sensations and only one had a prosthesis in place only for cosmetic reasons, at last follow up. CONCLUSIONS: Although FQA is a significantly body disfiguring procedure, but in large tumours of shoulder girdle, this is a viable option for local control of the disease. Based on our study, although relatively small sample size, we propose the combined anteroposterior approach to be safe and reliable for advanced shoulder girdle tumours.

Defect Coverage after Forequarter Amputation-A Systematic Review Assessing Different Surgical Approaches.

Autologous fillet flaps are a common reconstructive option for large defects after forequarter amputation (FQA) due to advanced local malignancy or trauma. The inclusion of osseous structures into these has several advantages. This article therefore systematically reviews reconstructive options after FQA, using osteomusculocutaneous fillet flaps, with emphasis on personalized surgical technique and outcome. Additionally, we report on a case with an alternative surgical technique, which included targeted muscle reinnervation (TMR) of the flap. Our literature search was conducted in the PubMed and Cochrane databases. Studies that were identified were thoroughly scrutinized with regard to relevance, resulting in the inclusion of four studies (10 cases). FQA was predominantly a consequence of local malignancy. For vascular supply, the brachial artery was predominantly anastomosed to the subclavian artery and the brachial or cephalic vein to the subclavian or external jugular vein. Furthermore, we report on a case of a large osteosarcoma of the humerus. Extended FQA required the use of the forearm for defect coverage and shoulder contour reconstruction. Moreover, we performed TMR. Follow-up showed a satisfactory result and no phantom limb pain. In case of the need for free flap reconstruction after FQA, this review demonstrates the safety and advantage of osteomusculocutaneous fillet flaps. If the inclusion of the elbow joint into the flap is not possible, we recommend the use of the forearm, as described. Additionally, we advocate for the additional implementation of TMR, as it can be performed quickly and is likely to reduce phantom limb and neuroma pain.

Forequarter amputation post transarterial chemoembolization and radiation in synovial sarcoma: A case report.

INTRODUCTION AND IMPORTANCE: Forequarter amputation or interscapulathoracalis amputation is a major amputation procedure that involves the entire upper extremity, scapula, and a whole or part of the clavicula. Forequarter amputation is commonly used to control bleeding in malignant tumor cases in which no treatment is available for the extremities. CASE PRESENTATION: We report a case of forequarter amputation in a 25-year-old patient with synovial sarcoma. Transarterial chemoembolization (TACE) and radiation synovial sarcoma were performed in the patient to reduce bleeding. This technique may also be used for treating synovial sarcoma with massive bleeding. CLINICAL DISCUSSION: Despite forequarter amputation indications in malignant tumor cases and recurrent cancer cases, the effectiveness of this technique remains unclear. The patient was readmitted with a recurrent mass three months after surgery. CONCLUSION: In this study, TACE and radiotherapy are effective in controlling bleeding preoperatively and intraoperatively in patients with synovial sarcoma.

Case of Atypical Adenoid Hyperplasia of Lung with Polyostotic Fibrous Dysplasia and Diabetes Mellitus: A Random Coincidence or a Possible Unrecognized Syndromic Association?

INTRODUCTION: Fibrous dysplasia (FD) is a benign intramedullary pathologic condition that is characterized by the replacement of bone with fibrous tissue. FD may be monostotic or polyostotic with the craniofacial bones, and the proximal femur is most commonly involved. CASE REPORT: A 39-year-old lady presented to our hospital, a tertiary care center with asymmetric swelling of her arms, for over 20 years. Radiographs revealed gross enlargement with marrow expansion of the right humerus, scapula with ground-glass matrix, along with a multiseptated cystic appearance. Positron emission tomography-computed tomography screening for the activity of these lesions incidentally demonstrated a few lung nodules, which on biopsy was found to be atypical adenomatous hyperplasia. The lady also had endocrine dysfunction in the form of diabetes mellitus, for which she was on treatment. CONCLUSION: In this article, we briefly review the available literature to decipher if any of the associated syndromes with polyostotic FD (being the dominant clinical feature) are known to have associations which explain the above findings. There is a need to recognize the underlying pattern so that appropriate genetic counseling, if any, can be provided to such patients.

"Whoops" fixation of proximal humerus pathological fracture ended with forequarter amputation - Case report.

INTRODUCTION: Even with the advancement of limb salvage surgery techniques, forequarter amputation (FQA) is still used in orthopedic oncology. Even though it might pose catastrophic sequelae on the patient's lifestyle, debilitating one's ability to perform regular tasks, FQA is still considered as a treatment of last resort for huge fungating tumors of the upper extremity. CASE PRESENTATION: We present a case of an 18-year-old male patient, who was diagnosed in Libya with left proximal humerus fracture after a trivial trauma and underwent open reduction and internal fixation using k-wires as it was thought to be a simple fracture. Soon after, pain and swelling progressed severely and an open biopsy confirmed a diagnosis of osteosarcoma and imaging suggested metastatic disease to the lungs for which he was started on chemoradiotherapy. He was referred to our cancer center to continue his management and due to the aggressive nature of the tumor, the patient underwent palliative forequarter amputation followed by multiple lines of chemotherapy and radiotherapy, all of which failed to halt the progression of the disease. The patient was lost to follow up due to his decision to go back to Libya. CONCLUSION: "Whoops" surgeries are fixated upon repairing fractures without looking for the alarming signs on radiographs to exclude pathological entity. As in our case, the procedure done escalated the osteosarcoma into such a massive fungating tumor due to the violation of the osteosarcoma pseudo capsule, in which the only available option is to do a palliative forequarter amputation.

Rehabilitation after Forequarter Amputation for Left Scapula Chondrosarcoma：A Case Report / The Japanese Journal of Rehabilitation Medicine

Forequarter amputation is a rare procedure, performed mainly for patients with malignant bone and soft tissue tumors. The present case involved a 59-year-old man with left scapula chondrosarcoma. Rehabilitation began on the second day after amputation for a left shoulder chondrosarcoma. We performed early mobilization, wound management, mirror therapy for phantom pain, strength training for the remaining muscles, and activities of daily living (ADL)/instrumental ADL (IADL) training for only the remaining upper limb. In addition, we made a shoulder disarticulation prosthesis. Six months after the operation, the International Society of Limb Salvage-Musculoskeletal Tumor Society functional score was 36.7％ for 6 items and 73.3％ for 3 items, while the Disability of Arm, Shoulder and Hand score was 31.7. The patient-reported outcome had a low score because of the lack of an upper limb, including the scapula. However, when he was discharged from the hospital, he gained self-care independence with only the remaining upper limb and resumed fishing as a hobby. We suggest that rehabilitation after forequarter amputation requires careful intervention based on a deep evaluation of the patient's ADL/IADL, hobbies, and quality of life, in accordance with the patient's lifestyle.

Rehabilitation after Forequarter Amputation for Left Scapula Chondrosarcoma：A Case Report / The Japanese Journal of Rehabilitation Medicine

Forequarter amputation is a rare procedure, performed mainly for patients with malignant bone and soft tissue tumors. The present case involved a 59-year-old man with left scapula chondrosarcoma. Rehabilitation began on the second day after amputation for a left shoulder chondrosarcoma. We performed early mobilization, wound management, mirror therapy for phantom pain, strength training for the remaining muscles, and activities of daily living (ADL)/instrumental ADL (IADL) training for only the remaining upper limb. In addition, we made a shoulder disarticulation prosthesis. Six months after the operation, the International Society of Limb Salvage-Musculoskeletal Tumor Society functional score was 36.7％ for 6 items and 73.3％ for 3 items, while the Disability of Arm, Shoulder and Hand score was 31.7. The patient-reported outcome had a low score because of the lack of an upper limb, including the scapula. However, when he was discharged from the hospital, he gained self-care independence with only the remaining upper limb and resumed fishing as a hobby. We suggest that rehabilitation after forequarter amputation requires careful intervention based on a deep evaluation of the patient's ADL/IADL, hobbies, and quality of life, in accordance with the patient's lifestyle.

Targeted Muscle Reinnervation and the Volar Forearm Filet Flap for Forequarter Amputation: Description of Operative Technique.

Targeted muscle reinnervation after upper-extremity amputation has demonstrated improved outcomes with myoelectric prosthesis function and postoperative neuropathic pain. This technique has been established in the setting of shoulder disarticulation as well as transhumeral and transradial amputations, but a detailed technique of targeted muscle reinnervation with free tissue transfer from the volar forearm after forequarter amputation has not yet been described. Here, we describe a technique using a volar forearm filet flap to achieve simultaneously satisfactory soft tissue coverage after resection of a tumor from the chest wall and targeted muscle reinnervation of the brachial plexus.

Open traumatic scapulothoracic dissociation: Case report of a rare injury.

Open traumatic scapulothoracic dissociation is a rare and devastating injury. We are reporting a 21-year-old male factory worker who sustained a traumatic open scapulothoracic dissociation. His left arm was caught in conveyer belts resulting the arm, scapula, clavicle, and pectoral muscle torn from the body by tremendous traction force. He presented with pulseless, flail and cold limb and was promptly resuscitated and surgically managed with forequarter amputation.

Rotational Pedicle Myocutaneous Forearm Fillet Flap Used to Fill Forequarter Amputation Defect: Indications and Uses.

A full-thickness fourth-degree burn to a large area of the upper extremity may require a forequarter amputation. Whereas our case describes a burn injury, forequarter amputations may more commonly be done in oncological surgery. In addition to the challenge of providing well-vascularized tissue coverage, the burn patient may also pose the complication of respiratory compromise in a systemically ill person. Fillet flaps have often been utilized as "spare part" reconstruction. Although previous forequarter amputations have been covered with free myocutanous forearm fillet flaps, we devised a rotational pedicle myocutaneous forearm fillet flap that might be less complex than a microvascular reconstruction. This article describes the technique and advantages of the pedicle fillet flap of the upper limb. This technique eliminates the risks of delayed warm ischemia time and avoids additional morbidity of donor sites. Although we sought to find a simpler, more rapid procedure for a burn patient, the pedicle forearm fillet flap has applications for both burn and oncological forequarter amputation defects. It provides a good combination of large tissue coverage with maximum perfusion of muscle bulk. The pedicle flap also enabled us to keep the distal part vascularized and to "bank" it for later use when the recipient area was well vascularized and free of infection.

The development of a low-cost three-dimensional printed shoulder, arm, and hand prostheses for children.

BACKGROUND AND AIM: The prosthetic options for higher level amputees are limited and costly. Advancements in computer-aided design programs and three-dimensional printing offer the possibility of designing and manufacturing transitional prostheses at very low cost. The aim of this project was to describe an inexpensive three-dimensional printed mechanical shoulder prosthesis to assist a pre-selected subject in performing bi-manual activities. TECHNIQUE: The main function of the body-powered, manually adjusted three-dimensional printed shoulder prosthesis is to provide a cost-effective, highly customized transitional device to individuals with congenital or acquired forequarter amputations. DISCUSSION: After testing the prototype on a young research participant, a partial correction of the patient's spinal deviation was noted due to the counterweight of the device. The patient's family also reported improved balance and performance of some bimanual activities after 2 weeks of using the device. Limitations of the design include low grip strength and low durability. Clinical relevance The prosthetic options for higher level amputees are limited and costly. The low-cost three-dimensional printed shoulder prosthesis described in this study can be used as a transitional device in preparation for a more sophisticated shoulder prosthesis.

Free fillet flap application to cover forequarter or traumatic amputation of an upper extremity: A case report.

Reusing tissue of amputated or unsalvageable limbs to reconstruct soft tissue defects is one aspect of the "spare parts concept." Using a free fillet flap in such situations enables the successful formation of a proximal stump with the length needed to cover a large defect from forequarter amputation without risking additional donor-site morbidity. The use of free fillet flaps for reconstruction after forequarter and traumatic upper extremity amputations is illustrated here in a case report. A 41-year old patient required a forequarter amputation to resect a desmoid tumor, resulting in an extensive soft-tissue defect of the upper extremity. A free fillet flap of the amputated arm and an additional local epaulette flap were used to reconstruct the defect. At 9 months after the procedure, a satisfactory result with a very well healed flap was attained. Free fillet flaps can be used successfully for reconstruction of large upper extremity defects, without risking additional donor-site morbidity. © 2015 Wiley Periodicals, Inc. Microsurgery 36:700-704, 2016.

Forequarter amputation: a safe rescue procedure in a curative and palliative setting in high-grade malignoma of the shoulder girdle.

BACKGROUND: Forequarter amputation (FQA) is a surgical treatment of tumors in the upper extremity and shoulder girdle that infiltrate the neurovascular bundles. In both curative and palliative settings, FQA can serve as an effective oncological treatment. METHODS: This study presents the FQA-related data of 30 patients (mean age 50 years) treated between 2000 and 2012. Their medical condition was high-grade bone or soft tissue sarcoma in 26 and high-grade carcinoma in four cases. RESULTS: Mean operation time was 119 min. One major and five minor complications occurred in the postoperative period. Resection margins were wide in 91 % of patients. Local recurrence was observed in four patients after 19 months on average. Patients treated with curative intention had a 5-year survival chance of 39 %. Average survival after palliative amputation was 11 months. CONCLUSIONS: FQA provides an opportunity for adequate oncological margins in large tumors, while offering relief from tumor-induced distress in palliative situations.

Giant Chondrosarcoma of Proximal Humerus in an Adult Female Patient: A Case Report.

Chondrosarcoma is the third most common primary tumour of the bone, after myeloma and osteosarcoma. Most of the chondrosarcoma grow slowly and rarely metastasize, and they have an excellent prognosis after adequate surgery. However most of them are chemo or radio-resistant. We report a case of primary chondrosarcoma of proximal humerus in a 36-year-old female who presented with a six years history of left shoulder swelling and restricted range of motion. Trucut biopsy showed a well-differentiated chondrosarcoma. The patient underwent forequarter amputation of left upper limb and was started on chemotherapy following operation.

Giant Chondrosarcoma of Proximal Humerus in an Adult Female Patient: A Case Report

Chondrosarcoma is the third most common primary tumour of the bone, after myeloma and osteosarcoma. Most of the chondrosarcoma grow slowly and rarely metastasize, and they have an excellent prognosis after adequate surgery. However most of them are chemo or radio-resistant. We report a case of primary chondrosarcoma of proximal humerus in a 36-year-old female who presented with a six years history of left shoulder swelling and restricted range of motion. Trucut biopsy showed a well-differentiated chondrosarcoma. The patient underwent forequarter amputation of left upper limb and was started on chemotherapy following operation.

Interscapulothoracic (forequarter) amputation for malignant tumors involving the upper extremity: surgical technique and case series.

BACKGROUND: Forequarter amputation (FQA) is reserved for large, multifocal, or recurrent tumors affecting the shoulder and upper extremity. Although it is performed less frequently with the advancement of limb salvage surgery, FQA remains an important treatment in select patients. The purpose of this study is to illustrate the surgical technique in a case series of 4 patients. METHODS: Between 2010 and 2012, 4 patients (mean age, 61 years; range, 36-78 years) presented with malignant disease of the upper extremity that was not amenable to or had failed limb salvage. All patients had FQA by the illustrated anterior clavicular osteotomy technique. Patient data were retrospectively reviewed from preoperative workup until last follow-up or death. RESULTS: All patients had tumors that involved major neurovascular structures of the upper extremity and shoulder girdle. One presented with neuroendocrine carcinoma and has achieved local control after FQA. Three presented with high-grade sarcoma. One of these had recurrence after prior limb salvage and neoadjuvant radiation and unfortunately succumbed to metastatic disease 6 months after FQA. An additional sarcoma patient who presented after shoulder arthroscopy for a "labral cyst" with recurrent and fulminant synovial sarcoma succumbed to her disease. The remaining sarcoma patient has had no recurrence and minimal phantom pain at last follow-up. DISCUSSION: Obtaining vascular control early in the procedure is crucial to minimize blood loss. When it is indicated, FQA is a relatively safe and reliable procedure for dealing with otherwise challenging tumors of the shoulder girdle and upper extremity. LEVEL OF EVIDENCE: Level IV, case series, treatment study.

Shoulder silhouette and axilla reconstruction with free composite elbow tissue transfer following interscapulothoracic amputation.

Interscapulothoracic amputation (ISTA) encompasses the removal of the upper limb, scapula and clavicle. As the reconstructive and oncologic limb-saving techniques improved, the indications for this formidable procedure decreased. However, it is still the appropriate procedure in cases with extensive oncologic or traumatic involvement of the shoulder girdle. Following ISTA, the surgeon is not only faced with a large defect but also with severe functional and aesthetic impairments. A solution to these problems is the immediate reconstruction with a free composite transfer from the amputated extremity. We successfully treated three oncologic cases and one traumatic case using this technique. The recipient vessels included the subclavian artery and vein in three cases and the internal thoracic vessels in one case. After a mean follow-up time of 4.5 years, two of the three tumour patients were free of recurrent disease. In all cases stable wound closure was achieved. Three out of four patients would opt for surgery again, in spite of the high occurrence of complications. One patient died after a 14-year event-free postoperative course. We conclude that the defect following ISTA can be successfully covered using a free composite tissue transfer of the amputated disease-free elbow and forearm, while simultaneously reconstructing the shoulder silhouette and axilla. This procedure reduces functional and aesthetic impairments and improves the quality of life.

Periscapular amputation as treatment for brachial plexopathy secondary to recurrent breast carcinoma: a case series and review of the literature.

AIMS: Recurrent breast carcinoma with brachial plexus involvement is often misinterpreted as a radiation- or chemotherapy-induced brachial plexopathy. We review a case series of 4 patients at our institution within a 1-year period, and describe their diagnostic workup and treatment with a palliative periscapular amputation. Our aim is to describe this entity, indications and benefits of this procedure, when required for progressive disease, with the goal of raising a collective index of suspicion to aid in earlier diagnosis. METHODS: Four patients with recurrent axillary breast cancer and symptoms consistent with a brachial plexopathy were prospectively collected over a 1-year period. A Pubmed search was conducted; pertinent articles were reviewed and reported. RESULTS: Patients presented with intractable pain and flaccid paralysis of the ipsilateral limb. All had been previously treated with surgical resection, axillary lymph node dissection, chemotherapy, and radiation therapy. Average time from breast surgery to presentation was 78.75 months (range 11-216 months.) Workup included MRI and biopsy to confirm recurrence. Periscapular amputation was performed for each patient, all of who experienced subjective pain relief postoperatively. Three of the 4 patients are still living; one patient died of disease. CONCLUSION: Breast cancer survivors presenting with a brachial plexopathy should raise suspicion for recurrent disease. Close evaluation with MRI is the best first step in diagnosis. Although periscapular amputation is an aggressive surgical treatment, it is an acceptable option when disease has progressed to neurovascular involvement and a functionless limb.